Over the last 20 years, the application of non-invasive

4278 Chin Med J 2014;127 (24) Perspective Application of non-invasive ventilation in China over 20 years Wang Chen and Zhang Xilong Keywords: non-in...
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4278

Chin Med J 2014;127 (24)

Perspective Application of non-invasive ventilation in China over 20 years Wang Chen and Zhang Xilong Keywords: non-invasive ventilation; China

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ver the last 20 years, the application of non-invasive ventilation (NIV) in China has progressively increased both in the hospital and extrahospital setting. The history of the NIV and its increasing spread in the clinical practice over China are one of the most important results of the cooperation between medicine and non-invasive mechanic technology.

Application of NIV in sleep disordered breathing (SDB) In 1986, after six-month training in the sleep center of Stanford University, Dr. Huang XZ set up the first sleep lab in China. However, the development of this area was still very slow, by 1997 there were only 4–5 sleep labs in China, and upper airway surgery was the major treatment for snoring and obstructive sleep apnea, and the use of a continuous positive airway pressure (CPAP) machine was uncommon.1 CPAP began its clinical use in China for patients with obstructive sleep apnea hypopnea syndrome (OSAHS) in 1987 and it was first reported in medical journal by Huang et al2 in 1991. Later on, however, as the consequences of sleep apnea hypopnea syndrome (SAHS) was more and more awared and well-known for its remarkable nocturnal intermittent hypoxiemia, hypercapnia, cerebrocardiovascular complications and so on, the desire for effective therapy on SAHS became more and more strong. With an acceleration of the development of sleep medicine after 1998, now it is estimated that there are more than 1 500 sleep labs in China, almost all university hospitals and hospitals at province or lower levels have established sleep labs, and the new NIV devices including CPAP, autoCPAP and bilevel positive airway pressure (BiPAP) have became more and more popular. So far, CPAP has been served as the backbone of OSAHS therapy in China.1 Over the past 20 years, various features have been incorporated into imported CPAP devices, including ramps, automatic leak compensation and humidification, and the choice and sophistication of CPAP accessories such as masks have increased dramatically in order to improve patients’ compliance and NIV’s efficacy. As auto-adjusting positive airway pressure (APAP) devices are an emerging treatment alternative to fixed-pressure CPAP therapy for OSAHS patients, APAP has acquired its wider use in China

since the first report of clinical use for OSAHS patients in 1998.3 Nowadays, an awareness of OSAHS, a better compliance and a rapid economical growth in China have put together to make more and more Chinese OSAHS patients accept and afford CPAP therapy. In 2002 Bi-PAP NIV was first reported for treatment of OSAHS.4 Since then more and more reports were published in China about clinical use of BiPAP for OSAHS, overlap syndrome, obesity hypoventilation syndrome (OHS), SAHS with heart failure or bronchial asthma.5-8 It seems BiPAP NIV in China is prone to be chosen for OSAHS patients with weaker respiratory muscle force or potential hypercapnia. In recent years, auto-trilevel NIV device has been reported in clinical use for OHS patients with OSAHS.9 The prelimilary clinical study showed autotrilevel PAP ventilation is superior over fixed BiPAP ventilaiton for treatment of OHS with coexisting moderate to severe OSAS, since this novel PAP mode can achieve a higher efficacy in simultaneous removal of residual apnea hypopnea events and correction of hypercapnia as well as in achieving a higher sleep quality and lower daytime sleepiness.9 With the invention and import of adaptive servo-ventilation (ASV) device, Zhang et al10 first reported their clinical practice in China for treatment of Cheyne stocke respiration (CSR) with ASV in patients with congestive heart failure in 2006. Following that, they first reported in the world the efficacy of ASV for residual sleepiness in OSAHS patients.11 Their report indicated residual sleepiness in OSAHS patients was associated with residual central sleep apnea (CSA) or complex sleep apnea which can not be solved by conventional CPAP only, and since ASV could eliminate not only obstructive sleep apnea, but also CSA events more effectively than ordinary CPAP, ASV could be served as a tool to treat and screen residual sleepiness associated with CSA for OSAHS patients. As the OSAHS in China is highly prevalent and a huge population of OSAHS patients are still under-diagnosed DOI: 10.3760/cma.j.issn.0366-6999.20142006 China-Japan Friendship Hospital, Beijing 100029, China (Wang C) Department of Respirology Medicine, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China (Zhang XL) Correspondence to: Wang Chen, China-Japan Friendship Hospital, Beijing 100029, China (Email: [email protected])

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and without receiving effective treatment, a rapid and sustainable development of sleep labs is going on year after year in China, where NIV home treatment for OSAHS is still facing a chance of further rapid development.

ventilation strategy under guidance of PIC window as a switch point could significantly shorten the duration of invasive ventilation, decrease the incidence of VAP, and reduce hospital mortality.20

NIV for acute respiratory failure (ARF)

Since PIC window has been recognized as a novel approach to identifying candidates for weaning in selected populations, sequencial ventilation has be set as a rule in clinical treatment of AECOPD in China and such a rule has been put into several famous guidelines in China such as “Clinical application guideline of mechanical ventilation” in 2006, “Guideline for diagnosis and treatment of COPD” in 2007, and “Mechanic ventilation guideline for AECOPD patients” in 2007.21-23

In 1992, application of NIV was first reported in China about its efficacy for patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). This report showed that NIV could significantly reduce endotracheal intubation rate by 30% and mortality by 20%.12 Since then, the advent of NIV has radically changed the management of ARF in China. In 2005, a national multiple-center study further proved the efficacy of NIV for AECOPD patients with respiratory failure. This clinical study is a randomized control study with the largest sample in China, which reported NIV treatment could reduce intubation rate from 15.2% to 4.7% (P=0.002) and faster improve blood gas parameters.13 14

From the late stage of 1990s, Prof. Wang et al at the Beijing Research Institute of Respiratory Diseases began to apply NIV for weaning of previously intubated stable patients with AECOPD. This shift therapy from invasive intubated mechanical ventilation to NIV is also called invasive - noninvasive sequencial ventilation. A national collaborative study of multiple centers proved that the strategy of such sequencial ventilation could really improve the prognosis of patients.15 In China, 80%–90% AECOPD cases occur as a result of bronchial-pulmonary inflammation. A significant proportion of them further develop into hypercapnic respiratory failure which requires invasive ventilatory support. In order to restore respiratory function and avoid time-dependent complications, some studies have been conducted to search for an optimal timing to replace invasive ventilation with NIV. The key in sequencial ventilation is to find the optimal timing as a switch point for a successful shift from invasive to NIV.16 The finding of pulmonary infection control (PIC) window as a switch point is a breakthrough for a successful shift.17 PIC window has been defined as a prompt stage of controlled pulmonary infection following artificial airway establishment, sputum drainage and antibiotic administration. It was marked by thinning and decrease of sputum; clearing of sputum cloudiness; decreases in body temperature, radiographic pulmonary infiltrations and blood leukocyte count.18 Wang et al19 proposed this stage as an optimal timing to replace invasive ventilation with NIV so that ventilatory insufficiency and respiratory muscle fatigue may be improved and lower respiratory tract infection and ventilator-associated pneumonia (VAP) can be avoided. Meta analysis demonstrated that so far there have been at least 4 clinical studies in which 227 patients participated and the results unequivocally proved that sequencial

With the use of NIV, the first multicenter randomized controlled trial in China for patients with acute lung injury (ALI) showed that NIV significantly reduced endotracheal intubation rate and hospital mortality and it was reported in 2012.24 Encouraged by the success from NIV treatment mentioned above, NIV has been increasingly used to avoid or serve as an alternative to endotracheal intubation in China. Compared with medical therapy and in some instances with invasive ventilation, NIV remarkably improves survival and reduces complications in selected patients with ARF.

Application of NIV in respiratory failure resulting from infectious diseases of respiratory tract In 2003 when acute respiratory syndrome (SARS) caused by a novel coronavirus was epidemic in China, NIV played an important and successful role in rescuing many patients with severe SARS which had developed into various degrees of respiratory failure. With standard protective measures against coronavirus during the performance of NIV for SARS patients, NIV therapy itself showed no harmful effects of SARS spread to health care workers.25 In 2009, a novel H1N1 Influenza virus emerged in China. Since patients with H1N1 Influenza could have various degrees of ARF. NIV was then applied in China as the firstline intervention for different extents of ARF induced by H1N1 Influenza. A lot of experience was obtained through successful rescue with NIV for patients with severe H1N1 Influenza.26 In order to timely indentify who need NIV and who need endotracheal intubation, NIV was usually tried first during the treatment for early acute respiratory distress syndrome associated with H1N1. Owing to the high demand for critical care beds during the epidemic of H1N1 Influenza, NIV also played a role in reducing the estimated load of intensive care unit in China.27

Reform and improvement of components associated with NIV devices As early as 1990s, it was noticed by Chinese doctors that the adverse effects of repeated breathing on ventilation

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because of the dead space in masks during NIV. In view of this, new styles of masks were made in China in which enough expiratory pores were added and the effects of repeated breath were therefore greatly reduced. Additionally, a special pore in a mask was set for inserting and fixing gastric tube because gastric feeding was sometimes needed for some patients on NIV. Some manuscripts were published about effects of reformed masks on dead space during NIV and effects of different types of masks on efficacy of NIV for COPD patients.28,29

in Thorax about readmission rates and life threatening events in COPD survivors treated with NIV for hypercapnic ARF and they found that COPD patients with hypercapnic ARF who survive following treatment with NIV had a high risk of readmission and life threatening events. In the same year, Chu et al37 first reported their success in using NIV to treat patients who refused endotracheal intubation. At the same year they also reported their follow-up study on prognosis of AECOPD patients with the application of NIV therapy.36

Standardized application and popularization of NIV in the mainland of China

In 2006 and 2009 Hui et al38,39 published their studies in Chest about assessing air and particle dispersion in treatment of SARS with NIV. They found that substantial exposure to exhaled air occurs within a 1-m region, from patients receiving NIV via the ComfortFull 2 mask and the Image 3 mask, with more diffuse leakage from the latter, especially at higher inspiratory positive airway pressure (IPAP). In 2010 Cheung et al40 first reported in Hong Kong that home NIV treatment could reduce reoccurrence of ARF in COPD patients.

In order to have NIV application standardized and popular in the mainland of China, the Chinese Respiratory Society published “Consensus of non-invasive positive pressure ventilation experts” in 2009.30 In addition, many various types of conferences and training courses for education of NIV knowledge and practical skills have been hold in China year after year beginning from late 1990s. So far NIV has been incorporated into the Spread program of “Ten year 100 plans” organized by The National Ministry of Health of China. By promoting the standardized application of NIV with better knowledge of the physiopathological bases of ventilation and of its continuous applications in daily clinical practice and by perfecting the elements required for the correct application of this technique, the clinical and scientific advances represented by the development of NIV in the mainland of China have been greatly pushed forward not only in large hospitals but also in many smaller hospitals at basic level.

Application and research of NIV in Hong Kong NIV began its use in Hong Kong in 1990. Up to now about 96% AECOPD patients with respiratory failure have received NIV therapy in Hong Kong.31 It was reported that in 2004 the rate of patients who received home mechanic ventilation treatment to the whole population of Hong Kong is about 30 000 : 100 000.32 In those who undergo home mechanic ventilation, 95% are treated with NIV, and about 50% of them are COPD patients.32 Multiple clinical NIV studies in Hong Kong revealed that the nasal mask was less well tolerated than the full face mask in patients with ARF.33 In 2004 Cheung et al34 reported their clinical practice about using NIV in the treatment of ARF in SARS and they concluded that NIV was effective in the treatment of ARF caused by SARS, and its use was safe for health-care workers. In 2005 Yam et al35 reported another manuscript about their experience in treatment of SARS and reached the conclusion that compared to invasive mechanical ventilation, NIV as initial ventilatory support for ARF in the presence of SARS appeared to be associated with reduced intubation need and mortality. In 2004 Chu et al36 reported

Summary Huge progress in application of NIV has taken place in China over the past 20 years. However, further efforts are still needed to elevate the NIV application levels and pursue a standardized and popularized NIV treatment in more fields. An enhancement is expected in the hospitals of China in terms of staffing, material resources, variability of material used, and availability of support systems. Although NIV is provided to patients with acute disease in most of the hospitals, the number and type of patients receiving home NIV therapy need to be increased. With the widened indications and intensified education of NIV practice, China poses a great potentiality for further development of NIV application. REFERENCES 1. Han F. Development of sleep medicine in China. Chin Med J 2009; 122: 1462-1463. 2. Huang XZ, Wu QY, Li LY, Ma Y, Luo WC, Xu YX, et al. Nasal continuous positive airway pressure therapy in obstructive sleep apnea syndrome (in Chinese). Chin J Tuberc Respir Dis 1991; 14: 225-227. 3. Huang XZ, Xiao Y, Zou D, Wu QY. Auto CPAP Set system for diagnosis and therapy of sleep breathing disorders (in Chinese). Chin J Tuberc Respir Dis 1998; 21: 468-470. 4. Mansukhani MP, Kolla BP, Olson EJ, Ramar K, Morgenthaler TI. Bilevel positive airway pressure for obstructive sleep apnea. Expert Rev Med Devices 2014; 11: 283-294. 5. Chen Z, Liu SY, Chen BY. New type Bi-level positive airway pressure (Bi-PAP) in treating overlap syndrome (in Chinese). Chin J Nosocomiol 2006; 16: 894-895. 6. Wu ZY, Tang SY, Liu CL, Li YJ. Clinical observation of noninvasive positive pressure ventilation for obesity hypoventilation syndrome (in Chinese). J Pract Diagn Ther 2010; 24: 469-470.

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(Received August 22, 2014) Edited by Ji Yuanyuan